EAR INFECTIONS

DOES YOUR CHILD HAVE AN EAR INFECTION? HOW TO TELL.

Your child has a bothersome cold for a week. Her nasal
discharge turns a little green and her cough starts to keep
you all up at night. Then one night she is up every hour
extremely fussy with a fever. You take her into the doctor
in the morning almost certain she has another ear infection.

Ear infections are one of the most worrisome illnesses
for both parents and children to go through, especially if
they frequently recur. They also are the most common reason
for antibiotic prescriptions. Here's a guide to help you
understand why ear infections occur, how to best treat them,
and most importantly, how you can prevent them from
happening too often.

EIGHT MAIN SYMPTOMS OF AN EAR INFECTION

Your child may have 2 or more of these symptoms:

Cold symptoms  keep in mind that ear infections are
almost always preceded by a cold. Often a clear runny
nose will turn yellow or green before an ear infection
sets in.

Fussiness during the day or night

Complaining of ear pain or hearing loss

Night-waking more frequently

Unwillingness to lie flat

Fever  usually low grade (101Ί - 102Ί); may not have a
fever.

Sudden increase in fussiness during a cold

Ear drainage  if you see blood or pus draining out of
the ear, then it is probably an infection with a
ruptured eardrum. DON'T WORRY! These almost always heal
just fine, and once the eardrum ruptures the pain
subsides.

YOUR CHILD IS UNLIKELY TO HAVE AN EAR INFECTION IF:

1. No cold symptoms  if your child has some of
the above symptoms but does not have a cold, an ear
infection is less likely, unless your child has had an ear
infection in the past without a cold.

2. Pulling at the ears or batting the ears in
infants less than 1 year of age.
Infants less than one are unable to precisely localize their
ear pain. This means that they cannot tell that the pain is
coming from the ear or from structures near the ear. Infants
can pull on or bat at their ears for two other common
reasons:

Teething  Baby thinks the pain from sore gums is coming
from the ears

Because they like playing with their ears  Infants are
fascinated with these strange appendages that are
sticking out of the side of their head. They love to
explore them, play with them, and especially to stick
their finger into that strange hole in the middle.

3. No complaints of ear pain in a child who is old
enough to tell you, usually by age two or three.

HOW CAN I TELL IF IT'S AN EAR INFECTION OR JUST
TEETHING?

Are you tired of taking your fussy baby into the doctor
just to check her ears, only to be told its probably just
teething? TO help you decide, with teething:

Pain usually starts at four months of age and will come
and go until the two-year molars are in.

Tugging or digging at the ears with no cold symptoms or
fever

Fussiness or night waking with no cold symptoms or fever

May have low fever less than 101

Teething does not cause a runny nose, only drool.

HOW DO EAR INFECTIONS OCCUR

Anatomy lesson. The ear is divided into three
parts: the outer ear canal, the middle ear space where
infections occur, and the inner ear where the nerves and
balance center are. A thin, membranous eardrum divides the
outer and middle ear. The middle ear space is also connected
to the back of the nose via the Eustachian tube.

Immature Eustachian tube. In infants and young
children this tube is much shorter and is angled. It is
therefore much easier for bacteria to migrate from the nose
and throat up into the middle ear space. As the child grows
this tube becomes more vertical, so germs have to travel "up
hill" to reach the middle ear. This is one-reason children
"outgrow" ear infections.

Colds. When your child has a cold, the nasal
passages get swollen and mucus collects in the back of the
nose. This environment is a breeding ground for the bacteria
that normally live in the nose and throat to begin to
overgrow. Mucus is also secreted within the middle ear space
just as it is in the sinuses.

Bacterial invasion. Germs migrate up through the
Eustachian tube and into the middle ear space where they
multiply within the mucus that is stuck there. Pus begins to
form and soon the middle ear space is filled with bacteria,
pus and thick mucus.

Ear pain. This pus causes the eardrum to bulge
causing pain. It is this red, bulging pus-colored eardrum
that the doctor can see by looking into the ear canal.

Diminished hearing. The discharge that collects in
the middle presses on the eardrum preventing it from
vibrating normally. This is what the doctor means by "fluid
in the middle ear." Also the fluid plugs the eustachian tube
and dampens the sound like the sensation in your ears during
air travel.

ARE EAR INFECTIONS CONTAGIOUS?

No, the bacteria inside the ear causing the infection are
not contagious. The cold virus that can lead to an ear
infection is contagious. Oftentimes, if the ear infection
occurs a week after the cold begins, the child is no longer
contagious.

HOW ARE EAR INFECTIONS TREATED?

Ear pain  click here for help on how to treat the
pain. Getting through the night:

Acetaminophen or
ibuprofen are effective pain relievers for ear
pain. You can safely use both medications together if
one alone is not enough. Click on each medication for
dosage.

Warm compress  apply a warm washcloth to the
ear.

Warm olive oil, vegetable oil, or garlic oil 
put several drops of one of these into the ear. MAKE
SURE THE OIL ISNT TOO HOT.

Anesthetic eardrops  if the above remedies
arent enough, these are available by prescription and
can numb the eardrum to minimize the pain for an hour or
two.

WARNING  if you see any liquid or pus draining
out of the ear, DO NOTPUT ANY OF THE ABOVE DROPS INTO
THE EAR. See below under ear drainage.

Antibiotics  a seven-day course is the current
recommendation, unless your doctor feels a longer course is
indicated. The whole issue of antibiotics can be confusing
to parents. Here are some general guidelines to help you:

Amoxicillin  "the pink stuff"  this is the
standard first-line treatment used by most doctors, and
rightly so. It works well most of the time, is
inexpensive, tastes pretty good, and is easy on the
stomach and intestines.

Azithromycin, Augmentin (amoxicillin/clavulinate
mix), double dose amoxicillin, cefuroxime  this are all
common second and third line choices.

A new combination of Augmentin plus extra amoxicillin
called Augmentin ES has been shown to be very
effective in treating resistant ear infections. Your
doctor may prescribe both.

Finish the prescribed course  even if you child
is feeling better after two or three days, it is best to
complete at least seven days of treatment to help ensure
the infection doesn't come back.

Ruptured eardrum  if this occurs, your doctor will
probably also prescribe an eardrop that is a mix of
antibiotic and hydrocortisone. This helps the ear canal
heal.

Avoid antibiotic resistance - But doctor,
amoxicillin doesn't work for my child, and it's so hard to
give it to her three times a day! Can I please have the once
a day for only five days stuff? Be careful about doing this.
Always taking a stronger, more convenient antibiotic can
make the bacteria that dwell in your child more resistant to
the stronger antibiotics, and can make future infections
more difficult to treat. Even if amoxicillin hasn't worked
once or twice in the past, chances are that this new
infection is a different bacteria that is sensitive to
amoxicillin, especially if more than two months have passed
since the last antibiotic. The good news is amoxicillin now
comes in a twice-a-day form, and treatment is usually only
seven days, not ten.

When to use a stronger antibiotic  it is usually
best to start out with the simple amoxicillin. Here are some
reasons to go with something stronger:

If the fever and fussiness are not improving after 48
 72 hours of an antibiotic, your child may need a
stronger one.

If amoxicillin has not worked two or three times in the
past, then it's ok to start with a stronger antibiotic
for future infections.

If your child has taken amoxicillin in the past six
weeks, and then develops another ear infection, chances
are that this infection is resistant and needs a
stronger antibiotic.

If your child is allergic to amoxicillin

If the infection is still present after one course of
amoxicillin

Important note  the antibiotics only take care of the
bacteria causing the ear infection. They don't treat the
virus that is causing the underlying cold symptoms. So
don't expect the runny nose and cough to improve for 3
to 14 days.

ARE ANTIBIOTICS ABSOLUTELY NECESSARY TO TREAT EAR
INFECTIONS?

No, they are not absolutely necessary, but they are very
helpful for several reasons:

Antibiotics will help your child feel better faster by
eliminating the bacteria, which in turn reduces the
fever and ear pain more quickly. Children generally feel
better after one or two days of antibiotics.

Allowing an ear infection to heal on its own usually
subjects a child to four to seven days of fever and ear
pain.

Antibiotics help prevent the very rare, but possible,
complications of an ear infection spreading into the
brain or bone surrounding the ear.

New research is suggesting that 80% of uncomplicated ear
infections will resolve within 4 to 7 days without
antibiotics. Parents who choose not to use antibiotics
can treat the pain and fever with Auralgan anesthetic
ear drops and ibuprofen or acetominophen.

MINIMIZING THE SIDE EFFECTS OF ANTIBIOTICS

Side effects can include:

Diarrhea

Fungal diaper rash

Oral thrush

Vomiting

Rash

HOW EAR INFECTIONS RESOLVE

There are two components of ear infections that need to
resolve:

Infection  the antibiotics usually take care of the
bacteria, which in turn resolves the fever and pain with
a few days.

Middle ear fluid  it takes much longer for this to
resolve, anywhere from a few days up to 3 months! The
fluid slowly drains out through the Eustachian tube down
into the nose. Taking repeated courses of antibiotics
does not speed up this process, since the fluid is
usually no longer infected with bacteria. Chronic nasal
congestion or allergies can block the Eustachian tube
and therefore prevent the ears from draining. Your
child's hearing may be muffled until the fluid drains
out. This is not permanent. See below on preventing ear
infections for tips on how to improve ear drainage.

Remember, since the runny nose and cough are usually
caused by a cold virus and not bacteria, it may be 3 
14 days before these symptoms resolve.

FOLLOW UP WITH THE DOCTOR

Most doctors will have you follow up anywhere from one to
four weeks after an ear infection. There are several reasons
for this:

To make sure the infection is clearing up

To make sure the middle ear fluid is draining out. If
the fluid stays around continuously for more than three
months, your doctor needs to know.

To help determine if the next ear infection is a new one
or a continuation of an old infection. This helps
determine which antibiotic to use.Your doctor may
perform a tympanogram  a rubber
probe that painlessly fits into your baby's ear canal
and measures how the eardrum vibrates. This helps
determine if there is any fluid left.

IMPORTANT NOTE: Try to avoid over-treating with
unnecessary repeated courses of antibiotics. At your
follow-up visit with your doctor, there may still be fluid
in the middle ear. If the ear is not red or bulging, and
your child is acting fine, you may not need another course
of antibiotics. Doctors will vary in how aggressive they
like to treat ear fluid. You may be able to spare your child
from an unnecessary course of antibiotics.

CHRONIC EAR FLUID

As stated above, sometimes it can take several months for
the fluid to drain out of the middle ear space. During this
period the hearing can be muffled. This isn't dangerous and
does not cause permanent hearing loss. Thankfully, the fluid
often drains out within two or three weeks. There are
several situations, however, when you do need to worry about
this fluid in the ear:

Eustachian tube dysfunction  this is a condition where
the Eustachian tube can't do its job correctly and the
middle ear doesn't drain. Causes include chronic sinus
infections, nasal allergies and frequent colds.

Fluid that stays in the ear for more than three to four
months can become thick and gooey, a term called "glue
ear". This type of fluid often needs to be drained
surgically by an ear specialist.

If this long period of muffled hearing occurs during the
first two years of life when language development is
crucial, it can cause speech delay. This is usually only
temporary, however, but the longer it goes on, the
longer the speech and hearing can be delayed.

If your child has several ear infections over a three to
four month period, and the fluid never really has time
to drain in between infections, this can cause a
prolonged period of muffled hearing.Again, don't worry
if it takes one or two months for the fluid to drain out
of your child's ear. This is common. We would like to
stress, however, the importance of proper follow-up with
your doctor to make sure it eventually resolves.

NINE STEPS TO PREVENTING EAR INFECTIONS

If your child has had several ear infections already, or
you simple wish to lower her risk of getting them in the
first place, here are some ways to prevent or at least
lessen the frequency and severity of ear infections:

1. Breastfeeding. There is no doubt whatsoever in
the medical literature that prolonged breastfeeding lowers
your child's chances of getting ear infections.

2. Daycare setting. Continuous exposure to other
children increases the risk that your child will catch more
colds, and consequently more ear infections. Crowded daycare
settings are a set up for germ sharing. If possible, switch
your child to a small, home daycare setting. This will lower
the risk.

3. Control allergies.

4. Feed baby upright. Lying down while
bottle-feeding can cause the milk to irritate the Eustachian
tube which can contribute to ear infections.

5. Keep the nose clear. When a runny nose and cold
start, do your best to keep the nose clear by using steam,
saline nose drops, and suctioning. See colds for more info
on this.

8. Eat more raw fruits and vegetables - these can
greatly boost your child's immune system and help fight off
infections.

MEDICAL PREVENTION FOR CHRONIC OR FREQUENT EAR
INFECTIONS

If your child is having frequent ear infections, more
aggressive prevention may be indicated. There are different
opinions as to the definition of chronic ear infections. How
many is too many?

More aggressive doctors may choose to begin medical
prevention if you child has more than three ear
infections in six months, or more than four in one year.

Less aggressive doctors may allow your child to have
more infections before recommending medical prevention.
We lean more in this direction.

Other factors such as hearing loss and speech delay may
warrant more aggressive treatment.

There are three forms of medical prevention:

Prophylactic antibiotics. This consists of a
once-a-day dose of amoxicillin or similar antibiotic.
There are two ways to do this:

Daily treatment for several months continuously,
such as through the winter season.

Start the daily treatment at the first sign of any
cold symptoms, and then continue the antibiotic for
7  10 days.

Advantage to taking prophylactic antibiotics is that
you avoid full dose courses of possibly stronger
antibiotics.

Disadvantage is that your child gets and antibiotic
possibly more often and this could contribute to
antibiotic resistance.

OUR PREFERENCE is to start the daily amoxicillin at
the first sign of cold symptoms.

Immunization. There is a new vaccine called
Prevnar that came out in 2000. Four doses are given
during the first two years of life. For children 15
months and older, one dose is enough. This vaccine helps
prevent infections from a bacterium called pneumococcus.
This bug causes pneumonia, blood infections, meningitis
and ear infections. The main purpose of this vaccine is
to prevent the more serious infections. It also can
prevent ear infections in two ways:

Decreased number of ear infections  this effect is
minimal. Studies have shown that this shot only
decreases ear infections by 10  20%.

Decreased ear infections from resistant pneumococcus
 this is considered a much more valuable benefit
from the shot. The vaccine has been shown to
significantly decrease the number of ear infections
caused by pneumococcus that are resistant to
standard antibiotics.

Ear tubes. These are tiny
tubes that an ENT specialist inserts into the eardrum
under general anesthesia. They usually stay in place for
6 months to over a year. There are several purposes
achieved by tubes:

To drain chronic ear fluid that may turn into "glue
ear".

To provide an outlet for middle ear fluid to drain
out as it begins to collect during a cold. This may
help prevent a full ear infection from occurring.

To preserve hearing and timely speech development by
avoiding long months of muffled hearing caused by
middle ear fluid.

To help prevent the rare complication of chronic
hearing loss caused by recurrent ear infections.

THE EAR TUBE CONTROVERSY

While ear tubes do have their place in treating recurrent
ear infections, there does exist some controversy over their
use. The advantages are listed above. Some common concerns
about tubes are:

Some doctors may be too quick to recommend ear tubes
before exhausting all other preventative measures or
before allowing enough time to allow the ears to clear
up without surgery.

As with any surgery, there are risks (though minimal) to
general anesthesia.

The tubes often leave a little scar covering
approximately one sixth of the eardrum. This scar is
often permanent. There does not seem to be any long-term
consequence of this scarring, but we're not completely
sure. Please note that recurrent ear infections with or
without eardrum rupture can also lead to scarring.

Please note that ear tubes don't always prevent ear
infections. Some children will still get as many
infections even with the tubes in, but the fluid drains
out right away.

OVERALL EAR TUBES DO HAVE A PROPER PLACE IN TREATING
RECURRENT EAR INFECTIONS WHEN USED APPROPRIATELY.

Many children benefit from ear tubes. Parents declare
their child is a new person. The ear infections are
gone. The hearing is improved. No more sleepless nights
with a crying child. No more endless courses of
antibiotics.

General indication for tubes are chronic ear fluid for
more than four to six months; or more than three ear
infections in six months or more than five in one year.
You and your doctor should decide together when it is
the right time for ear tubes for your child.